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Journal of Ultrasound (2008) xx, 1e5

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12 Ultrasound-guided injection of botulinum toxin 74

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A in the treatment of iliopsoas spasticity 76
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L.M. Sconfienza a,*, N. Perrone a, F. Lacelli b, C. Lentino c, G. Serafini b

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21 Di.Me.S. Sezione di Radiodiagnostica, Università degli Studi di Genova, Genova, Italy 83
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22 Dipartimento di Diagnostica per Immagini e Alta Tecnologia, AO Ospedale Santa Corona, Pietra Ligure (SV), Italy 84
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Dipartimento di Recupero e Riabilitazione funzionale, AO Ospedale Santa Corona, Pietra Ligure (SV), Italy 85
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28 KEYWORDS Abstract Purpose: Intramuscular injection of botulinum toxin A (BTX-A) is a common treat- 90
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29 Botulinum A toxin; ment for iliopsoas muscle spasticity, but it is not easy to position the needle in this muscle 91
30 Interventional without guidance. We describe an ultrasound-guided technique for the intramuscular injection 92
31 ultrasonography; of BTX-A to treat spasticity of the iliopsoas muscle. Its effectiveness was assessed in 10 pa- 93
32 Injection; tients. 94
33 Iliopsoas muscle; Method and materials: The ultrasound-guided technique for BTX-A injection was used on 10 95
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34 Cerebral palsy. patients. The needle was inserted into the muscle belly at an angle of 45 along the longitu- 96
35 dinal axis of the muscle when the patient’s condition allowed. 97
36 Results: In all cases, the iliopsoas muscle was easily identified and both the iliac and psoas 98
37 components were assessed. Introduction of the needle and drug injection was carried out en- 99
tirely under ultrasonographic guidance. The procedure was successful in all patients, even in
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39 those with a high-grade spasticity, and general anesthesia was not required. 101
40 Conclusions: This ultrasound-guided technique allows accurate guidance for the injection BTX- 102
41 A, and it can be considered as an alternate supportive therapy in patients with spasticity and 103
42 dystonia. 104
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44 Sommario Obiettivi: L’iniezione intramuscolare di tossina botulinica A (BTX-A) per il tratta- 106
45 mento della spasticità del muscolo ileopsoas è tecnica consolidata, ma è gravata da un’alta 107
46 difficoltà nel preciso posizionamento dell’ago. Scopo del nostro lavoro è descrivere una tecnica 108
47 ecoguidata per l’introduzione intramuscolare di tossina botulinica nel trattamento della spas- 109
48 ticità del muscolo ileopsoas e valutare l’efficacia terapeutica di questa terapia. 110
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49 Materiali e metodi: Dieci pazienti con spasticità cronica del muscolo ileopsoas sono stati trat- 111
50 tati mediante inoculazione ecoguidata intramuscolare di BTX-A. L’ago è stato introdotto in 112
51 sede intramuscolare nel contesto del muscolo con un’inclinazione di 45 sull’asse longitudinale 113
52 del muscolo stesso. 114
53 Risultati: In tutti i casi trattati, il muscolo ileopsoas è stato facilmente identificato e distinto 115
54 nelle sue componenti iliaca e psoas. L’intera procedura, sia di introduzione dell’ago sia di in- 116
55 iezione del farmaco nel sito corretto è stata monitorata ecograficamente. La procedura è stata 117
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58 * Corresponding author. Di.Me.S. Sezione di Radiodiagnostica, Università degli Studi di Genova, via L.B. Alberti 2, 16132 Genova, Italy. 120
59 E-mail address: io@lucasconfienza.it (L.M. Sconfienza). 121
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61 1971-3495/$ - see front matter ª 2008 Published by Elsevier Masson Srl. 123
62 doi:10.1016/j.jus.2008.05.002 124

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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2 L.M. Sconfienza et al.

125 eseguita con successo in tutti i casi, anche in quelli con intensa spasticità, senza ricorrere ad 187
126 alcuna anestesia generale. 188
127 Conclusioni: La tecnica ecografica descritta consente una guida precisa alla corretta inocula- 189
128 zione del farmaco. L’iniezione ecoguidata di BTX-A può essere considerata una terapia alter- 190
129 nativa di supporto nei pazienti con spasticità e distonia. 191
130 ª 2008 Published by Elsevier Masson Srl. 192
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134 capsule as markers, the sonographer can clearly locate the distal 196
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Introduction 197
portion of the iliopsoas and the neurovascular bundle, which lies
136 medial to the muscle. 198

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137 Botulinum toxin is a protein produced by Clostridium botu- In this study, we used an anterior approach, with the patient in 199
138 linum, which inhibits muscle contraction by transiently a supine position. The preferred site for BTX-A injections is the pre- 200
139 blocking the release of acetylcholine at the neuromuscular insertional segment of the distal portion of the iliopsoas muscle, 201
140 junction. In nature, there are 7 botulinum toxins identified proximal to the myotendinous junction, beneath the inguinal 202
141 with capital letters from A to G. Only 3 of these (toxins A, B, ligament.
203

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and E) are capable of provoking the botulinum intoxication The needle is introduced under US guidance in a caudocranial
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syndrome, also known as botulism. This condition is charac- direction at a 45 angle until its tip is correctly positioned in the
143 muscle. No needle guide was needed. Nevertheless, in patients with 205
144 terized by flaccid paralysis of the striated muscles and 206
severe spasticity, this approach is precluded by the strong hyper-
145 blockade of the cholinergic vegetative functions. The toxin 207
flexion of the thigh. In these cases, the drug should be injected into
146 inactivates certain membrane proteins that are essential the most distal portion of the muscle possible; the needle is inserted 208
for cellular function. This process involves the temporary

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147 in the axial plane with a lateromedial orientation. 209
148 inhibition of presynaptic acetylcholine release; conse- US was performed with a Philips iU22 scanner (Koninklijke 210
149 quently its effects are restricted to motor neurons that de- Philips Electronics N.V., The Netherlands) equipped with a 5e2 MHz 211
150 pend on cholinergic transmission (muscular plate, gland convex transducer and a 12e5 MHz high-resolution linear broad- 212
151 innervating cells) [1,2]. Injections of botulinum toxin A band array transducer.
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(BTX-A) have been shown to be effective [3e6] in the treat- The study was conducted according to the principles of the
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Declaration of Helsinki of 1964. Informed consent was obtained
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153 ment of etiologically diverse types of muscle spasms. Cor- 215
rect placement of the needle within the muscular from all patients.
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155 structure is essential to avoid adverse effects. Moreover, 217
unless one is certain that the toxin has indeed been in- Statistical analysis
156 218
157 jected into the muscle poor clinical outcomes cannot be re- 219
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liably attributed to a lack of response to BTX-A [6]. Post-treatment variations in VAS scores were assessed with a non-
158 parametric ManneWhitney U test. We considered P values < 0.05 to 220
159 The purpose of this paper was to describe an ultrasound 221
be statistically significant.
160 (US)-guided technique for the accurate injection of BTX-A 222
161 and to assess the results achieved with this technique in 223
patients with iliopsoas muscle spasticity. Results
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164 In all patients, the US examination allowed easy identifi- 226
Materials and methods
165 cation of the iliopsoas muscle and reliable guidance for 227
166 needle insertion and BTX-A injection. All patients had good 228
We treated 10 patients with spasticity of the iliopsoas muscle
167 responses to the therapy. No peri- or post-procedural 229
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caused by infantile cerebral palsy (CP) in 4 cases (2 hemiplegic


168 patients who were ambulatory and 2 nonambulatory patients, 1 di- complications occurred (Figs. 1 and 2). 230
169 plegic and 1 paraparetic; mean age 13  3.56 years); multiple scle- The patients who were ambulatory prior to treatment 231
170 rosis (MS) in 4 cases (all nonambulatory; mean age 44.75  8.85 presented significantly improved hip kinetics and spatio- 232
171 years); or spinal-cord trauma in 2 cases (both nonambulatory pa- temporal walking parameters. The nonambulatory MS 233
172 tients; mean age 32.50  2.12 years). Spasticity was assessed patients with postural alterations before the treatment 234
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173 with a Visual Analogue Scale (VAS) before and 40 days after the pro- showed significant improvement in the posture that facil- 235
174 cedure [7]. itated nursing care. 236
175 After the neuromuscular blocking, patients underwent a 4-week Patients with spinal lesions experienced remarkable 237
rehabilitative treatment.
176 reductions in muscle spasticity, which translated into less 238
We used a 22-gauge spinal needle to inoculate 150 units of BTX-
177 pain, better sleep (which was no longer interrupted by 239
A with a single injection (Dysport, Ipsen SA, France). The toxin
178 was injected only when the needle was located in the correct spastic contractions), and a better quality of life. 240
179 position. All patients presented significantly reduced muscle tone 241
180 with significant decreases (P < 0.01) in the VAS score (Table 242
181 Technique 1), increases in the passive range of motion of the hip, and 243
182 a reduction of spasms. 244
183 The iliopsoas is a deep muscle that is closely associated with the None of the patients required a second injection to 245
184 neurovascular bundle of the lower limb. For this reason, US achieve full therapeutic effects. 246
185 guidance is mandatory for correct placement of the needle prior Rehabilitative treatments proved to be easier to admin- 247
186 to the injection of BTX-A. Using the femoral head and the articular ister after this treatment. 248

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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249 spasticity, and cerebral palsy [4,5,9,10]. More recent appli- 311
250 cations include neuromuscular blockade of inappropriately 312
251 contracted sphincters (e.g., associated with spasmodic dys- 313
252 phonia, anal spasms, vaginism, achalasia, and altered ocu- 314
253 lar movements such as those of nystagmus) [11e13] and of 315
254 exocrine glands affected by autonomic hyperactivity (as in 316
255 hyperhidrosis or sialorrhea) [14,15]. The toxin has also been 317
256 successfully used in the treatment of pain associated with 318
257 the myofascial pain syndrome, lumbar back pain, mi- 319
258 graines, and tension headaches [16]. It is also widely used 320
259 to eliminate facial wrinkles [17]. 321
260 Though botulinum toxin is considered the most powerful 322

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261 poison in nature (a few nanograms are enough to kill an 323
262 adult man), the therapeutic window is definitely safe: 324
263 doses used in daily practice are 50e100 times lower than 325
264 the lethal dose. Moreover, central nervous system side 326
265 effects are unlikely since the toxin does not cross the 327

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266 brain-blood barrier. The widespread use and large-scale ap- 328
267 plication of this toxin are basically justified by the absence 329
268 of reports of significant side effects, the reversibility of its 330
Fig. 1 Ultrasonographic image obtained with a linear probe
269 action, and the fact that the treatment can be repeated if 331
(12e5 MHz). The needle (black arrows) has been inserted into
270 necessary. BTX-A is preferred over surgical approaches be- 332
the psoas muscle (*). F Z femoral head.
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We did not perform any ultrasound assessments of the
maximum level of efficacy of the injection, which was
achieved 20e29 days after the injection (mean 24.1  1.21
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relaxation, and it does not produce permanent lesions. Pa-
tient satisfaction is usually high, and the cost of treatment
is considerably lower than that based on conventional drug
therapy [18]. In most cases, the effects of BTX-A therapy
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276 days). All patients were followed for 6 months after the are evident for 2e3 days after the injection, and the max- 338
treatment monthly US scans. In all cases, satisfactory mus-
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277 imum effect is observed after about 3 weeks. They last up 339
278 cle relaxation was maintained for 3 months; in 4 patients to 3e4 months. After this period, the chemical denervation 340
279 the effects lasted 4 months, and 2 experienced beneficial induced by the toxin is hindered by spontaneous neo- 341
280 effects for 6 months. innervation. Some patients (2e3%) do not respond to the 342
281 therapy, and 5e7% develop an antibody response to the A 343
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282 Discussion serotype of the toxin. In these cases, serotype B toxin is 344
283 used. Its clinical effects are the same as those of BTX-A, 345
284 Clostridium botulinum was discovered by Emile Pierre van but the doses used are different [19]. 346
285 Ermengem in 1895. The therapeutic use of botulinum toxin Spasticity of the iliopsoas muscle can cause several 347
problems in patients undergoing rehabilitative therapy. In
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286 was first proposed in 1973 by Scott et al., who used the se- 348
287 rotype A toxin to correct strabismus [8]. Injections of botu- patients who are ambulatory, it alters hip kinematics during 349
288 linum toxin are currently used to treat primary and walking, hindering the physiologic extension that occurs 350
289 secondary dystonia, post-stroke and post-traumatic during the central-late terminal period of the step. In 351
290 nonambulatory patients, iliopsoas spasticity can cause the 352
291 non-ambulatory patient to assume an incorrect posture in 353
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292 the wheelchair, and this can lead to myotendinous retrac- 354
293 tion that is difficult to reduce. These problems are even 355
294 more serious if the spasticity also affects other muscle 356
295 groups or both lower limbs. 357
296 Different techniques for the treatment of iliopsoas 358
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297 spasticity with BTX-A have been proposed. Ward [20] used 359
298 palpation alone to position the needle (with an anterior 360
299 or posterior approach). Willenborg et al. [21] employed 361
300 US to locate the muscle and verified the correct position 362
301 of the needle by electrostimulation. The computed tomog- 363
302 raphy-guided technique described in 2000 by Porta et al. 364
303 had several disadvantages, including high costs, long exam- 365
304 ination times, use of ionizing radiation, and the need for se- 366
305 dation especially in young patients [22]. In 2003, Westhoff 367
306 et al. [6] described a US-guided technique with an anterior 368
307 approach, which allowed the needle to be positioned 369
308 Fig. 2 Ultrasonographic image obtained with a convex probe quickly, safely, and without the use of ionizing radiation. 370
309 (5e2 MHz). The needle (black arrows) has been inserted into Our experience indicates that the choice of whether to 371
310 the psoas muscle (*). F Z femoral head. use a convex or linear US probe depends exclusively on the 372

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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373 Table 1 Characteristics of the 10 patients with iliopsoas Conflict of interest 435
374 spasticity
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375 The authors have no conflict of interest. 437
376 Age Cause of VAS (T Z 0) VAS Z 40 438
377 spasticity days 439
378 1 8 CP 7.5 3.1 References Q1 440
379 2 16 CP 5.4 2.1 441
380 3 13 CP 6.5 3.4 [1] Erbguth FJ. From poison to remedy: the chequered history of 442
381 4 15 CP 6.5 2.9 botulinum toxin. J Neural Transm, in press. 443
382 5 57 MS 7.6 3.9 [2] Erbguth FJ. Historical notes on botulism, Clostridium botuli- 444
383 6 42 MS 7.4 3.4 num, botulinum toxin, and the idea of the therapeutic use 445
384 7 36 MS 5.2 2.2 of the toxin. Mov Disord 2004;19(Suppl. 8):S2e6. 446

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385 8 44 MS 7.9 2.8 [3] Kessler KR, Skutta M, Benecke R. Long-term treatment of cer- 447
386 9 34 Spinal lesion 6.9 2.8 vical dystonia with botulinum toxin A: efficacy, safety, and an- 448
387 tibody frequency. J Neurol 1999;246:265e74. 449
10 31 Spinal lesion 5.9 1.9
[4] Bakheit AM, Severa S, Cosgrove A, et al. Safety profile and ef-
388 VAS Z Visual Analogue Scale, CP Z cerebral palsy, MS Z multi-
450
ficacy of botulinum toxin A (Dysport) in children with muscle
389 ple sclerosis. spasticity. Dev Med Child Neurol 2001;43:234e8.
451

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390 [5] Kirschner J, Berweck S, Mall V, Korinthenbeg R, Heinen F. Bot- 452
391 ulinum toxin treatment in cerebral palsy: evidence for a new 453
392 biometrical features of the patient. Although many diffi- treatment option. J Neurol 2001;248(Suppl. 1):28e30. 454
393 culties can arise during the treatment of spastic patients, [6] Westhoff B, Seller K, Wild A, Jaeger M, Krauspe R. Ultra- 455
394 we did not use a needle guide for any of the procedures we sound-guided botulinum toxin injection technique for the 456

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395 performed. However, this aid may be helpful for less iliopsoas muscle. Dev Med Child Neurol 2003 Dec;45(12): 457
396 experienced operators. The pre- and post-treatment clin- 829e32. 458
397 ical evaluations included a preliminary physiatric examina- [7] Vles GF, de Louw AJ, Speth LA, et al. Visual Analogue Scale to 459
score the effects of Botulinum Toxin A treatment in children
398 tion, VAS assessment [7], evaluation of muscle tone 460
with cerebral palsy in daily clinical practice. Eur J Paediatr
399 (modified Ashworth scale) [23], assessments of the active 461
Neurol, in press.
400 and passive ranges of movement of the hip and of autonomy [8] Scott AB, Rosenbaum A, Collins CC. Pharmacologic weakening 462
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401 in activities of daily living (Barthel ADL index) [24,25]. The of extraocular muscles. Invest Ophthalmol 1973;12:924e7. 463
402 Ashworth and Barthel indexes are more relevant within the [9] Deleplanque B, Lagueny A, Flurin V, et al. Botulinum toxin in 464
403 context of a broader program of rehabilitation. We pre- the management of spastic hip adductors in non-ambulatory 465
404 ferred to limit our evaluation to the general improvement cerebral palsy children. Rev Chir Orthop Reparatrice Appar 466
405 perceived by the patients and assessed with the VAS. Mot 2002;88:279e85. 467
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406 [10] Molenaers G, Eyssen M, Desloovere K, Jonkers I, De Cock P. A 468


407 multilevel approach to botulinum toxin type A treatment of 469
Conclusions the (ilio)psoas in spasticity in cerebral palsy. Eur J Neurol
408 470
1999;6(Suppl. 4):59e62.
409 The US-guided technique for BTX-A treatment of iliopsoas [11] Dutton JJ, Fowler AM. Botulinum toxin in ophthalmology. Surv
471
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410 spasticity allows the operator to verify the position of the Ophtalmol 2007;52(1):13e31. 472
411 needle prior to injection of the toxin. In this manner, [12] Jones OM. Towards safer treatments for benign anorectal dis- 473
412 incorrect needle placement can be excluded as possible ease: the pharmacological manipulation of the internal anal 474
413 causes of nonresponse. The procedure is safe, rapid, and sphincter. Ann R Coll Surg Engl 2007;89(6):574e9. 475
414 [13] Watts CR, Truong D, Nye C. Evidence for the effectiveness of 476
economical and it can be repeat as needed without the
415 botulinum toxin for spasmodic dysphonia from high-quality re- 477
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risk of overexposure to ionizing radiation. The position of search designs. J Neural Transm, in press.
416 the needle can also be continuously monitored during the 478
417 [14] Schnider P, Binder M, Kittler H, Steinhoff N, Auff E. Uses of 479
injection, thus eliminating the risk of damage to the botulinum toxin. Lancet 1997;349:953.
418 neurovascular bundle. 480
[15] Raval TH, Elliott CA. Botulinum toxin injection to the salivary
419 However, it must be stressed that this procedure should glands for the treatment of sialorrhea with chronic aspiration.
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420 482
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be performed only by expert radiologists who have received Ann Otol Rhinol Laryngol 2008 Feb;117(2):118e22.
421 adequate training. [16] Lew HL, Lee EH, Castaneda A, Klima R, Date E. Therapeutic 483
422 The US-guided intramuscular injection of BTX-A is an use of botulinum toxin type A in treating neck and upper- 484
423 effective treatment for iliopsoas spasticity. It can be back pain of myofascial origin: a pilot study. Arch Phys Med 485
424 Rehabil 2008 Jan;89(1):75e80. 486
considered an effective form of supporting therapy in
425 [17] Sator PG. Skin treatments and dermatological procedures to 487
patients with spasticity and/or dystonia of the lower limbs. promote youthful skin. Clin Interv Aging 2006;1(1):51e6.
426 This treatment considerably reduces the discomfort asso- 488
427 [18] Kinnet D. Botulinum toxin A injections in children: technique 489
ciated with iliopsoas spasticity, and it can be used in and dosing issues. Am J Phys Med Rehabil 2004;83(Suppl.
428 tandem with conventional rehabilitative therapy. 490
10):s59e64.
429 [19] Costa J, Espı́rito-Santo C, Borges A, et al. Botulinum toxin type
491
430 B for cervical dystonia. Cochrane Database Syst Rev 2005;(1). 492
431 Acknowledgements CD004315. 493
432 [20] Ward AB. Botulinum toxin type A treatment of hip and thigh 494
433 The authors thank Mr. Gianluca Di Cara for his kind spasticity: a technique for injection of psoas major muscle. 495
434 contribution to this paper. Eur J Neurol 1999;6(Suppl. 4):91e3. 496

Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002
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497 [21] Willenborg MJ, Shilt JS, Smitz BP, Estrada RL, Castle JA, [23] Bohannon RW, Smith MB. Interrater reliability of a modified 505
498 Koman LA. Technique for iliopsoas ultrasound-guided active Ashworth scale of muscle spasticity. Phys Ther 1987;67(2): 506
499 electromyography-directed botulinum A toxin injection in ce- 206e7. 507
500 rebral palsy. J Pediatr Orthop 2002;22:165e8. [24] Mahoney FD, Barthel DW. Functional evaluation: the Barthel 508
501 [22] Porta M. A comparative trial of botulinum toxin type A and index. MD State Med J 1965;145:61e3. 509
502 methylprednisolone for the treatment of myofascial pain syn- [25] Katz S, Ford AB, Moskovitz RW, Jackson BA, Jaffe MW. Studies of 510
503 drome and pain from chronic muscle spasm. Pain 2000;85: illness in the aged. The Index of ADL: a standardized measure of 511
504 101e5. biological and psychosocial function. JAMA 1963;185:914e9. 512

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Please cite this article in press as: Sconfienza LM, et al., Ultrasound-guided injection of botulinum toxin A in the treatment of iliopsoas
spasticity, Journal of Ultrasound (2008), doi:10.1016/j.jus.2008.05.002